Introduction

A combination of physical, occupational, and speech therapy; psychiatric or psychologic counseling; and social work services to help debilitated persons maintain or recover physical capacities.

Rehabilitation is typically needed by patients who, for example, have had a stroke, hip fracture, or limb amputation. It is also commonly needed by patients, especially elderly patients, who have become deconditioned because of prolonged bed rest (eg, after a myocardial infarction, heart surgery, or a serious illness).

The elderly, even if cognitively impaired, can benefit from rehabilitation. Age alone is not a reason to postpone or deny rehabilitation. However, the elderly may recover slowly because they lack endurance (due to cardiovascular complications), because they have depression or dementia, or because muscle strength, joint mobility, coordination, or agility is diminished.

Programs designed specifically for the elderly are preferable, because the elderly often have different goals, require less intensive rehabilitation, and need different types of care than do younger patients. In age-segregated programs, elderly patients are less likely to compare their progress with that of younger patients and become discouraged, and the social work aspects of postdischarge care can be more readily integrated. Some programs are designed for specific clinical situations (eg, recovery from hip fracture surgery); patients with similar conditions can work together toward common goals by encouraging each other and reinforcing the rehabilitation training.

The rehabilitation team (a specialized type of geriatric interdisciplinary team) coordinates the services needed by debilitated patients and develops and implements a comprehensive treatment plan. Team members may include physicians, nurses, physical therapists, occupational therapists, speech therapists, psychologists, social workers, other health care practitioners, the patient, and family members. Frequently, a physiatrist or a geriatrician coordinates the team. The case manager or the nurse updates the treatment plan as necessary. The nurse augments formal therapy and reinforces the skills learned by patients. The nurse can also help prevent secondary disabilities (eg, contractures, pressure sores), thus helping shorten the hospital stay, improve the quality of life, and accelerate rehabilitation for patients.

Referral: To initiate formal rehabilitation, the physician writes a referral (similar to a prescription) to a physiatrist, therapist, or rehabilitation center. The referral establishes the goals of therapy and therefore should be appropriately detailed, including relevant information (eg, type of illness or injury, date of onset) and initial instructions (eg, indicating the specific therapy needed--see Figure 28-1). Although vague instructions (eg, "for physical therapy") are often accepted, they are not adequate to detail a rehabilitation program. Physicians unfamiliar with writing referrals can consult with a senior therapist, physiatrist, or orthopedic surgeon.

Goals of therapy: Establishing goals of rehabilitation helps determine the setting and method of rehabilitation. For the elderly, the goal of rehabilitation is often limited to restoration of the ability to perform as many activities of daily living (ADLs) (see Table 4-3) as possible. This goal may differ from that for younger patients, whose goal more often is to achieve full, unrestricted function.

The rehabilitation team establishes short-term goals, which are specific, and long-term goals, which are more general. A patient's progress in achieving short-term goals must be followed closely for rehabilitation to be efficient. The treatment plan can be used to track progress; it lists the patient's problems, a short-term goal for each problem, and a method and a deadline for achieving each goal. The patient is encouraged to achieve each short-term goal and is informed of any changes in goals. Improvements in patient performance are noted in the treatment plan.

The goals of therapy may have to be altered if the patient is unwilling or unable (financially or otherwise) to undergo lengthy rehabilitation (eg, complete rehabilitation requires 6 or 8 weeks after a hip fracture and several months after a stroke). Therefore, the duration of rehabilitative therapy should be discussed with the patient and family members before rehabilitation is started. For complete rehabilitation, the patient must reach the premorbid level of functioning. As soon as the patient can transfer with minimum assistance (usually in 5 to 10 days), treatment can be given at home. Family members can be trained to give rehabilitative therapy. If feasible, a visiting physical therapist or occupational therapist can be used.

Discharge planning: Rehabilitation team members must begin discharge planning as soon as the patient is admitted. Discharge planning is based on the patient's wishes, anticipated functional outcome, and psychosocial history, which includes the patient's premorbid personality, ethnic and religious beliefs, lifestyle (eg, career), coping skills, family relationships, and financial resources. Discharge planning can be hindered if a patient or family member denies physical disability.

Patient and caregiver issues: Patient and family education is an important part of the discharge process, particularly when the patient is discharged into the community. Often, the nurse is the team member primarily responsible for this education. Patients are taught to perform ADLs (including how to walk), to maintain newly regained functions, and to reduce the risk of accidents (eg, falls, cuts, burns) and secondary disabilities. Family members are taught how to help the patient be as independent as possible, so that they do not overprotect the patient (leading to decreased functional status and increased dependence) or neglect the patient's primary needs (leading to feelings of rejection, which may cause depression or interfere with physical functioning).

Emotional support from family and friends is essential. It may take many forms. Spiritual support and counseling by the patient's peers or by religious advisors can be indispensable.